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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ754138 (SDO 0358006)
Regular
Jul 13, 2012

IGNACIO GOMEZ vs. PREMIUM ROOF SERVICES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board reconsidered a decision regarding an applicant injured while employed as a roofer. The applicant was awarded home healthcare services, but the initial judge found no authority to order payment to the applicant's wife. The Board granted reconsideration, finding that the applicant has the right to choose his home healthcare provider, especially given the inadequate services previously provided by the defendant's agency. Therefore, the Board amended the award to ensure the applicant receives the stipulated attendant care/housekeeping services from his wife.

Workers' Compensation Appeals BoardPremium Roof ServicesInc.State Compensation Insurance FundIgnacio GomezFindings Award and Ordersrooferindustrial injurylow backstipulated award
References
Case No. ADJ8331259
Regular
Dec 21, 2012

MARIELA GOMEZ vs. PROVIDENCE FARMS, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The Board adopted the WCJ's report, emphasizing that the defendant's failure to properly notify the applicant about changing treating physicians within the Medical Provider Network (MPN) resulted in a denial of necessary medical treatment. This failure to inform the applicant of her rights, particularly regarding physician selection and dispute resolution processes within the MPN, constituted a neglect or refusal to provide reasonable medical treatment, as established by precedent. Consequently, the applicant was permitted to continue receiving treatment outside the MPN until she could begin care with a designated physician within the network.

Workers' Compensation Appeals BoardProvidence FarmsLLCZenith Insurance CompanyMariela GomezADJ8331259Order Denying ReconsiderationPetition for ReconsiderationMedical TreatmentMedical Provider Network
References
Case No. ADJ9285089
Regular
Aug 24, 2016

ANA RAMIREZ FARIAS vs. ABLE BUILDING MAINTENANCE, ZURICH NORTH AMERICA

The Appeals Board affirmed an arbitrator's decision that applicant Ana Ramirez Farias must transfer medical care to her employer's exclusive provider network, despite her continued treatment with Dr. Arthur Harris. The majority found that the collective bargaining agreement's provisions on medical treatment, negotiated under Labor Code section 3201.5, take precedence over general Medical Provider Network (MPN) statutes like section 4603.2(a)(2). The dissenting opinion argued that the collective bargaining agreement diminishes the applicant's statutory right to treatment and that section 4603.2(a)(2) should apply due to the agreement's silence on transfer of care disputes.

Labor Code section 3201.7Labor Code section 3201.5(b)Alternative Dispute Resolution (ADR)self-procure treatmentmedical controlexclusive provider networkcarve-out agreementMedical Provider Network (MPN)collective bargaining agreementagreed list of providers
References
Case No. ADJ2706622 (POM 0301949)
Regular
Jan 17, 2012

JANETTE CHAVEZ vs. SUPERIOR TRAILER, BARRETT SERVICES, INC.

The Workers' Compensation Appeals Board granted reconsideration of a prior finding that the defendant failed to provide proper notice of its Medical Provider Network (MPN). The defendant provided applicant's attorney with MPN provider lists, but one list provided months before the applicant's treatment did not include Dr. Higginbotham. Despite this, the Board found that the defendant provided adequate notice by including a website URL for the MPN directory and printed lists, establishing that Dr. Higginbotham was not an approved provider. Consequently, the Board amended the findings to state the defendant is not liable for Dr. Higginbotham's lien.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNLiensFindings of FactReconsiderationWCJCompromise and ReleasePetition for ReconsiderationReport and Recommendation
References
Case No. ADJ8531754
Regular
Mar 11, 2019

ARTURO TRUJILLO vs. TIC THE INDUSTRIAL COMPANY, THE HARTFORD INSURANCE

The Workers' Compensation Appeals Board (WCAB) vacated its prior order granting reconsideration and dismissed the defendant's petition for reconsideration. The WCAB granted the defendant's petition for removal, rescinded the WCJ's findings and orders, and returned the case to the trial level for further proceedings. This decision stemmed from a dispute over whether an Agreed Medical Evaluator's (AME) interview with the applicant's wife and the applicant's provision of medical records at the AME's deposition constituted impermissible ex parte communication. The WCAB found that the interview with the wife was permissible as a collateral source to supplement the applicant's potentially impaired memory due to a brain injury, and that the provision of records at the deposition was not ex parte as the defendant was present. However, the WCAB remanded the case for the WCJ to determine if the applicant improperly provided information to the AME, as parties must agree on what information is provided to an AME.

Agreed Medical EvaluatorEx Parte CommunicationPetition for RemovalMedical-Legal ReportingCollateral InterviewApplicant's WifeDepositionsMedical RecordsSubstantial EvidenceLabor Code Section 4062.3
References
Case No. ADJ7555799 (MF) ADJ7561888
Regular
Sep 08, 2017

REYNA PANIAGUA vs. T & R BANGI'S AGRICULTURAL SERVICES, INC., SEABRIGHT INSURANCE, administered by ENSTAR GROUP, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking reconsideration of a finding that her employer did not refuse to provide medical treatment. The applicant's designated Medical Provider Network (MPN) physicians were unable to treat her, leading to delays and her eventual notification that a provider was no longer accepting new patients. Despite the applicant's frustration and inability to secure treatment within the MPN, the Board affirmed the original finding. The Board concluded there was insufficient evidence that the defendant neglected or refused to provide the requested medical treatment.

Workers Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)Self-Procured TreatmentNeglect or Refusal to Provide TreatmentStipulations With Request for AwardCompromise and ReleaseExpedited HearingDeclaration of David KestnerCentral Valley Occupational Medical Group (CVO)
References
Case No. ADJ8727749
Regular
Sep 26, 2013

CINDY VARGAS vs. SEARS HOLDINGS CORPORATION, SEDGWICK CMS

This case concerns an employer's petition to remove a WCJ's order compelling them to provide a complete list of their Medical Provider Network (MPN) in specific specialties. The employer argued this was overly burdensome, preferring to limit the list to providers within 30 miles of the applicant's residence. The Appeals Board denied removal, finding the WCJ's order was not burdensome or harassing under Administrative Director Rule 9767.12(f)(3). The Board noted the employer could fulfill the order electronically via CD or website, even if limited to the requested specialties.

Workers' Compensation Appeals BoardPetition for RemovalMedical Provider NetworkMPN listingTitle 8 Cal. Reg. § 9767.12(f)(3)Administrative Director Ruleregional area listingcomplete provider listingelectronic listingCD
References
Case No. ADJ9957492 ADJ9957588 ADJ10160287
Regular
Jul 14, 2017

JULIO NUNEZ vs. BARRETT BUSINESS SERVICES, INC., ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a petition for reconsideration by Barrett Business Services, Inc. and Ace American Insurance Company. The defendants sought to overturn a finding that the applicant, Julio Nunez, was entitled to choose his own psychotherapy provider due to a delay in treatment authorization. The Board agreed with the WCJ that the defendant's failure to authorize treatment with a chosen MPN provider after receiving proper notification established the applicant's right to seek care outside the MPN. This entitlement arose from specific instances of delayed and denied authorization for psychotherapy.

Workers' Compensation Appeals BoardReconsiderationJoint Findings and OrderPsychotherapy treatmentMedical Provider NetworkMPNProvider of choiceAuthorizationDelay of treatmentDenial of treatment
References
Case No. ADJ10013565
Regular
Nov 05, 2018

ANTONIO GUZMAN vs. KLEAN SWEEP PARKING LOT SERVICE, INC., STATE COMPENSATION INSURANCE FUND, INSURANCE COMPANY OF THE WEST

The Workers' Compensation Appeals Board (WCAB) granted Trucare Pharmacy's Petition for Reconsideration, rescinding the prior order to stay Trucare's lien. The WCAB found that the defendant failed to meet its burden of proof that Trucare was "controlled" by a criminally charged provider as defined by Labor Code section 139.21(a)(3). Specifically, there was no evidence that John Garbino, the criminally charged provider, was an officer, director, or 10% shareholder of Trucare Pharmacy. Therefore, Trucare's lien is not subject to a stay under Labor Code section 4615 and the case is returned for further proceedings.

Labor Code section 4615criminally charged providerjoint venturepartnershiplien claimantprovider statuscontrolled entitystatutory interpretationdue processadministrative director
References
Case No. ADJ4550283 (RIV 0082494)
Regular
May 06, 2016

PEDRO CABRERA vs. BUILDERS TRIM & DOOR, INC., GOLDEN EAGLE INSURANCE COMPANY

This case involves a lien claimant seeking reconsideration of a disallowed medical lien for psychological services. The Workers' Compensation Appeals Board denied reconsideration, upholding the judge's decision that the lien claimant failed to prove its services were medically necessary or rendered within the defendant's Medical Provider Network (MPN). The lien claimant also improperly attached unadmitted documents to its petition, violating procedural rules. Therefore, the defendant is not liable for the services provided outside the MPN.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings and OrderMedical legal expenseCompromise and ReleaseIndustrial injuryPsychological injuryCompensable consequenceMedical provider network (MPN)
References
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